Two Genealogies of Madness: Part Two

(Continued from here https://thebeetlebox.wordpress.com/2014/05/28/two-genealogies-of-madness-part-one/)

If our concepts of ‘madness” are socially constructed and as such don’t latch onto to an independent reality, it does indeed seem like a death knell for them. They are just fantasies, and worse than that, fantasies which were created to serve a malign social purpose- that of separation, ostracisation and false-reassurance.

This is where the above discussion of Nietzsche becomes important. The genealogy of morals succeeds in undermining the value of the “value-judgements good and evil” at least partly because Christianity cares about truth, and it cares about it’s value system being tied to some external truth about the world. But we do not need to see the conceptual framework behind the practice of psychiatry in this problematic way, as descriptive of a purely scientific phenomenon which is distinct from us and our own mode of life and flourishing .

Another brilliant imaginary-genealogist (though I doubt he would see himself as such) is Wittgenstein. In the opening pages of his “Philosophical Investigations” he lays the possible development of various “primitive language games” (designed as “objects of comparison” in order to “shed light” onto our own language. (130)) A key misconception about language that these are meant to erode is the idea that language is essentially descriptive (or even that language has a single essence at all.) To this end he gives accounts of language games with an obvious function, one that sometimes is to describe reality, though mostly involves other, equally important, purposes. (Indeed, the language games which are solely descriptive “shed light” very effectively on how far removed our language is from them.)

He invites his reader to think of the following use of language: “I send someone shopping.  I give him a slip marked ‘five red apples’.  He takes the slip to the shopkeeper, who opens the drawer marked ‘apples’, then he looks up the word ‘red’ in a table and finds a colour sample opposite it; then he says the series of cardinal numbers–I assume that he knows them by heart–up to the word ‘five’ and for each number he takes an apple of the same colour as the sample out of the drawer.–It is in this and similar ways that one operates with words.” (1) He follows this up with other more extensive examples of similar “primitive languages”, examples which share this pedagogical theme. “Now what do the words of this language signify?” asks Wittgenstein’s interlocutor about another one of these “languages”. “What is supposed to shew what they signify, if not the kind of use they have?” he responds “And we have already described that.” (10)

In the subsequent section he instructs the reader to “think of the tools in a tool-box: there is a hammer, pliers, a saw, a screw-driver, a ruler, a  glue-pot, glue, nails and screw.—The functions of words are as diverse as the functions of these  objects. (And in both cases there are similarities.)” (11)

These Wittgensteinian considerations have important consequences for other genealogies. The implicit Foucauldian criticism of the concepts surrounding “madness” is partly that they are unscientific and are created to perform a particular social role as opposed to reflecting reality.  However if language does not always need to “describe”, then our unmasking of a particular use of it as “non-descriptive” cannot be the end of the story. We need further critique of the “role” that this linguistic practice does play; in “Madness and Civilization”, as stated above, it is quite clearly malevolent, but it does not necessarily need to be.

In the opening chapters of “Madness Explained” Richard Bentall offers a historical account of the development of the system of psychiatric classification which we use. He starts much later than Foucault, with the work of the German psychiatrist Emil Kraepelin (and, according to Eyesenck’s Encyclopaedia of Psychology, the founder of psychiatry) and those who continued in that vein.

According to Bentall, the central idea that Kraepelin introduced to psychiatry was an understanding of mental illness in line with the rest of the medical model. He quotes Kraepelin:

“Judging from our experience in internal medicine it is a fair assumption that similar disease processes will produce identical symptom pictures, identical pathological anatomy and an identical aetiology.” (12) Bentall sees this “orthodox approach” as being reliant on two false assumptions: “first, that madness can be divided into a small number of diseases (for example, schizophrenia and manic depression) and, second, that the manifestations or “symptoms” of madness cannot be understood in terms of the psychology of the person who suffers from them.” (8) For Kraepelin, a particular aetiology (i.e. the cause of a disease or condition) leads to a discrete type of pathological anatomy, which in turn has a set of symptoms stemming from it.

Most of what Bentall does in “Madness Explained” has nothing to do with genealogy and instead involves rigorous scientific argument that the Kraepelinian picture  does not match up to any kind of psychological reality. Argument that as a categorial system of diagnosis it fails since diagnoses are neither jointly exhaustive or mutually exclusive (69), that any of the chemical or anatomical markers thought to be linked to certain sorts of mental illness only do so very ambiguously (171) and that the clinician’s empathetic and emotional understanding can completely determine what supposedly “objective” disease the patient is diagnosed with (386.) This is where much of the ‘meat’ of “Madness Explains” lies, and is clearly required reading for anyone interested in the objective validity of psychiatric diagnoses.

But all this aside, I still think that the first three “genealogical chapters” of “Madness Explained” have an important role to play in his overall thesis. Firstly, to almost re-quote Williams, Bentall has shown a “radical contingency in our current [psychiatric] conceptions.” They are not eternal, immutable categories. In fact, although not necessitated by coercive social forces, they are the creation of a single man, and that they were adopted and propagated so widely has something to do with both social forces and chance. The hold the Kraepelinian picture has on use is loosened: it is seen as a conceptual framework created at a particular point in time, not as how things necessarily are. (“One thinks that one is tracing the outline of the thing’s nature over and over again, and one is merely tracing round the frame through which we look at it” (Wittgenstein, 114.)

But secondly, and more importantly, the Kraepelinian picture is shown to be a framework created to do something. However, unlike in Foucault, what the framework was created to do does not undermine its continued use. Bentall’s genealogy recalls us to the point of psychiatry, that it doesn’t just aim to describe a world it aims to treat, to alleviate suffering and to cure. To do things instead of just represent things.  At least part of the point of his critique is that the concepts of psychiatry fall apart when we try and divorce them from these aims, since attempting to make people well is, at bottom, a normative discipline. (A point he makes brilliantly in his “Proposal to classify happiness as a psychiatric disorder.” http://jme.bmj.com/content/18/2/94)

The conclusion that Bentall draws from all this is that psychiatry, as it stands now in the Post-Kraepelinian tradition, it is ill-fitted to carry out that particular role. Instead of assisting people in getting ‘well’ again, and putting their life back on the path they wish it to go down, labels like schizophrenia, bipolar and depression get in the way of effective treatment. None of these terms help us to understand the causal factors behind or the prognosis of a particular case (174), the drug treatments which may be effective (93) and they bias professionals against the kinds of “talking cures” which attempt to unravel and alleviate these “illnesses” from a first-personal perspective. But these kinds of argument are only possible after his genealogy has rid us of the illusion that we must see mental illness in accordance with these terms, and we have understood them as only useful in so far as they aid us in doing something important.

Bentall attempts to replace the Kraepelinian picture with his own approach, the fundamental guiding principle being that “We should abandon psychiatric diagnoses altogether and instead try to explain and understand the actual experiences and behaviours of psychotic people.” This may seem debunking in the way that Foucault’s picture is; he has shown psychiatric classifications to be invalid and advised that we get rid of them.

But what is importantly left behind is psychiatry, clinical psychology, therapy and mental health nursing as enterprises. Whereas Foucault’s account of the function of “madness” as a concept is one that encourages us to abandon it altogether, Bentall preserves the importance of helping and healing some of the most vulnerable members of our society- his genealogy simply reminds us of how far current psychiatric practice is from that aim.

I think that genealogies like Foucault’s are important. I even think that they might be true, but they inevitably lead to what Nussbaum has called a “hip quietism”, presumably meant in the Catholic sense which involves an “annihilation of the will and passive absorption in contemplation”. (http://perso.uclouvain.be/mylene.botbol/Recherche/GenreBioethique/Nussbaum_NRO.htm)

It is vital to acknowledge the social forces and coercive role of the state behind our current concepts of “madness”, but it is also important to direct critiques at the right pressure point, to make them count. As Nietzsche notes “there is a world of difference between the reason for something coming into existence in the first place and the ultimate use to which it is put, its actual application and integration in a system of goals.”  The role of psychiatric services since the time of Kraepelin is inextricably linked to helping people recover. The fact that they systematically fail to adequately do so is, on their own terms, an outrage.

Bibliography

Bentall, R. (2003). Madness Explained.  Allen Lane

Foucault, M. (1965). Madness and Civilization. Random House

Nietzsche, F. (1996). On the Genealogy of Morality. OUP

Williams, B. (2004). Truth and Truthfulness. PUP

Wittgenstein, L. (2009, 4th ed). Philosophical Investigations. Blackwell. (All references for Wittgenstein are sections, not pages)

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6 responses to “Two Genealogies of Madness: Part Two

  1. Pingback: Two Genealogies of Madness: Part One | The Beetle Box

  2. Thanks for this Cat, great stuff. A few random thoughts:

    1) What are the differences between Foucault and Bentall? You say Bentall is more productive, but who is right?

    2) Nietzsche’s concern is with the value of morality, so what we need after we have unmasked its origins is a revaluation (Umwertung) of values. Foucault and especially Bentall seem to have done a lot of unmasking. But what about the revaluation? Which concepts *can* be useful for psychiatry?

    3) All this reminds me very much of Williams’ “Philosophy as a Humanistic Discipline”. In WIlliams’ terminology, the need for studying the history of a philosophy arises because our theories and concepts are not “vindicatory”, i.e. their supposed superiority is not necessarily convincing to someone with very different preconceptions from ours. It sounds like the same is true for psychiatry, and perhaps much more damagingly so than in philosophy (since even we moderns, on reflection, might be better off getting rid of our Kraepelinian preconceptions).

    4) It also reminds me of economics (sorry). Economics could do with some genealogy too, I’m guessing. Take e.g. Joan Robinson’s idea that marginal utility theory is at bottom motivated by the socialist ideology of its proponents (i.e. Wicksell and Marshall). I’m also pretty sure that the popularity of Friedman’s strange ideas about the methodology of economics has a lot to do with the perceived threat of communism during the cold war.

    5) What do you think is the right role of biomedical science in psychiatry? Are there cases where a physiological perspective might be useful? For instance, a friend of mine has thyroid dysfunction, and she has a history of being mentally unwell. She is much better now, which she attributes to having found the right medication for the physiological issue. Is hers a psychiatric problem at all?

  3. Thanks, B, these are all so useful.

    1) I think they’re probably both right.

    If you’re just talking about the facts, Bentall’s history is probably ‘more right’ that Foucault’s in that it is beyond academic dispute.

    However, since they’re writing about different time periods (Bentall’s genealogy starts after Foucault’s ends) this isn’t so important. Even if they were writing about the same period, I think it’s both true that madness has a social role to play in squishing some kind of existential angst , as well as a consciously articulated role of making people better.

    However a genealogy is more than just a collection of facts, it’s a tool meant to do something. What I dislike about Foucault isn’t that he’s wrong per se, it’s that he’s useless. To get out some more Nussbaum: “Feminist thinkers of the new symbolic type would appear to believe that the way to do feminist politics is to use words in a subversive way, in academic publications of lofty obscurity and disdainful abstractness. These symbolic gestures, it is believed, are themselves a form of political resistance; and so one need not engage with messy things such as legislatures and movements in order to act daringly.” Bentall is trying to reform psychiatry, and clearly uses his book as a tool to do so. It’s unclear what exactly Foucault is trying to do, other than show to the world just how intelligent he is.

    2) Yes! I wish I’d thought of this in reference to N! This is my point exactly, Foucault just unmasks (and given the shape of the function of “madness” that’s he’s unearthed that’s really all he can do.)

    Bentall, on the other hand, ultimately replaces the Kraepelinian conceptual framework with his own one. Whereas the structure of Foucault is something like “Our concept of madness has a function, that function is awful, we must liberate ourselves from it” Bentall’s, in my opinion is something like “Our concept of madness has a function, that function is poorly served by our present psychiatric practice, let’s get back to it.”

    This is the best possible summary of Bentall’s idea on what should replace the Kraepelinian paradigm. http://www.ncbi.nlm.nih.gov/pubmed/16300903 Even just the abstract is worth reading. Here’s a bit of it though: “I suggest that we therefore need to abandon psychiatric diagnoses altogether and must instead attempt to explain the specific complaints (‘symptoms’) that patients bring to our attention. These include hallucinations, delusional beliefs, thought and communication disorders, which are much more widely experienced than was previously thought (for example, about 10% of the population have experienced hallucinations.)”

  4. 3) Yes, I would definitely agree with this. I wish I’d had the space to quote some PHD, but I know if posts get too long you’ll be the only one who makes it to the bottom.

    I do think things are importantly different in psychiatry than philosophy, though re genealogies. Part of what’s wrong with the Kraepelinian picture is that it leads to bad science, and again much of Bentall’s book is spent bashing that. So even without studying the history of psychiatry, the theories and concepts are not vindicatory. I’m not sure what the equivalent in philosophy would be- conceptual incoherence? Huge conflict between our philosophy and the rest of our experience?

    That’s why I think Bentall is so neat. His genealogy works because it is a different kind of genealogy from the one seen in the humanities, because it has to be.

    4) Yes, please write this. Thankyou.

    5) I think a physiological perspective is often very useful (and so does Bentall, I believe, since at least part of what’s wrong the Kraepelinian picture is that it doesn’t help us correctly prescribe drugs for people.)

    I think the important question to ask is whether or not there is another level of explanation available. And whether or not it is useful to see things from that perspective instead.

    In your friend’s case, perhaps not. Maybe what was needed was just to sort out the underlying physiology (though bear in mind, most people talking about physiological explanations in psychiatry are mostly talking about brain-physiology, which is more tricky.) This definitely seems like the appropriate level of explanation here, just as often sorting out bad diet or lack of exercise can improve things like depression.

    What Bentall is against is the thought that the physiological perspective is the only one possible to adopt with respect to mental health issues. However strong you think the nature/nurture thing slides in the nature direction it’s clear that psychological therapies do help people untangle their problems. Some people seem to think that just because something has a particular physiology or brain anatomy the only way to change it is to go directly to that physiology or anatomy, and seem to forget that experience (like experiencing therapy) can change these things as well.

    An example from the ward. We had a catatonic patient in a couple of months ago. At that point all we could really do was medicate. Trying to get her to talk about her problems was a no starter because she wasn’t talking. But when she recovered a bit it became clear that the best thing to do for her long-term recovery was to attempt to work through all the issues she was currently having with her husband (anger and misery and hatred that she didn’t feel she could express to him.) It’s not an either or. Drugs (and very, very, *very* occasionally ECT) work directly on the physiology and can save lives when that’s all you have. However as soon as other levels of explanation become available to you for why someone is mentally unwell, I definitely think it’s better to try and work with those. (I would say Bentall probably agrees with this as well.)

    My next proper post is going to be about perspectives, though, so hold on!

  5. One more thought re 3). It seems to me psychology/psychiatry, like economics, is different from the traditional natural sciences in that we will never be sure of the precise mechanisms at work because the human mind is so complex. On the other hand, in contrast to philosophy, there are reasonably clear criteria as to what counts as a successful theory (or so one would hope), which might be to a large extent independent of our preconceptions (e.g. we want the patient to get *well*, and there is large overlap in what we think that means). So we can talk about “bad science” with reference to these criteria. Of course it’s not true that anything goes in philosophy either: some arguments are just bad, and some are so from anyone’s point of view.

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